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vital signs Flashcards

1
Q
A
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2
Q

What are vital signs?

A

Basic but very important components of physiologic assessment of the patient

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3
Q

What is the purpose of assessing vital signs?

A

Detect changes in health status, identify early warning signs, evaluate effectiveness of interventions

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4
Q

What does pulse oximetry measure?

A

The amount of oxygen available to tissues

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5
Q

What are baseline values in vital signs?

A

Initial vital signs used to identify changes in patient status

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6
Q

How often are vital signs assessments typically done for stable patients?

A

Every 4 to 8 hours

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7
Q

In what situations is vital signs assessment required?

A

On admission, physical assessment, routine monitoring, change in health status, before and after surgery, before and after medications, ongoing care, before discharge

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8
Q

What is the normal temperature range for a newborn to 3 months?

A

96 – 99.5 F

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9
Q

What is the normal pulse range for a 6-year-old?

A

60 - 100

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10
Q

What is the responsibility of a nurse regarding vital signs taken by UAP?

A

Interpretation of vital signs remains the responsibility of the licensed or registered nurse

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11
Q

What must the nurse ensure about UAP when delegating vital signs measurement?

A

They know the proper technique and what values need to be reported immediately

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12
Q

What is thermoregulation?

A

Physiologic and behavioral mechanisms that regulate the balance between heat production and heat loss

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13
Q

What part of the brain acts as the body thermostat?

A

Hypothalamus

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14
Q

What is the average normal adult oral temperature range?

A

96.31 to 99.34 F

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15
Q

Fill in the blank: Heat loss through direct contact is called _______.

A

[Conduction]

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16
Q

What are the types of heat loss?

A
  • Radiation
  • Conduction
  • Convection
  • Evaporation
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17
Q

What factors affect body temperature?

A
  • Age
  • Time of day
  • Hormonal changes
  • Environmental temperature
  • Illness
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18
Q

What is hypothermia?

A

Decreased body temperature and respirations, pale and cool skin, hypotension, disorientation

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19
Q

What is fever (pyrexia)?

A

A rise in body temperature above normal, caused by trauma or illness

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20
Q

What are the signs and symptoms of heatstroke?

A
  • Confusion
  • Delirium
  • Excessive thirst
  • Nausea
  • Muscle cramps
  • High temperature
  • High heart rate
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21
Q

What is the risk of taking rectal temperatures in young infants?

A

Rectal perforation

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22
Q

What should be done if mercury from a thermometer spills?

A

Do not touch spilled mercury; leave the area and consult local health department for disposal

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23
Q

What nonsteroidal drugs may be ordered to lower body temperature?

A
  • Ibuprofen
  • Acetaminophen
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24
Q

What can cause an increase in pulse rate?

A
  • Fever
  • Loss of blood
  • Stress
  • Hypoxia
  • Electrolyte imbalance
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25
Where is the temporal pulse located?
Where the temporal artery passes over the temporal bone of the head
26
What pulse site is used in cases of cardiac arrest?
Carotid pulse
27
What does the apical pulse measure?
Heart rate at the apex of the heart
28
True or False: The pulse rate typically decreases with age.
True
29
What is a common effect of smoking on body temperature?
Causes vasoconstriction, leading to a drop in skin temperature
30
Where is the brachial pulse located?
At the inner aspect of the arm ## Footnote Used to assess pulse in pediatric emergencies and to measure blood pressure.
31
What is the location of the radial pulse?
On the thumb side of the inner aspect of the wrist ## Footnote Where the radial artery runs along the radial bone.
32
When is the femoral pulse typically used?
In cases of cardiac arrest and for assessing circulation to the leg.
33
What is the purpose of the popliteal pulse assessment?
To determine circulation to the lower leg.
34
Where is the posterior tibial pulse located?
Medial surface of the ankle ## Footnote Used to determine circulation to the foot.
35
What does the pedal (dorsalis pedis) pulse assess?
Circulation to the foot.
36
What device is used to assess difficult-to-detect pulses?
Doppler ultrasound unit.
37
What should be done if the peripheral pulse is irregular?
Count an apical pulse for 1 full minute.
38
How is the pulse rate obtained in infants and children under 2 years of age?
By auscultating the apical pulse for a full minute.
39
What is a pulse deficit?
When the radial pulse rate is slower than the apical pulse rate.
40
What is the pulse intensity scale for 0?
Absent pulse (unable to palpate).
41
What causes tachycardia?
Factors include: * Drop in blood pressure * Elevated temperature * Anemia * Prolonged application to heat * Pain * Strong emotions such as fear or anxiety * Bronchodilators.
42
What is bradycardia?
A low heart rate (<60 bpm in the adult).
43
What are common causes of bradycardia?
Including: * Athletes during sleep * Hypothermia * Beta-blockers * Tracheal suctioning * Increased intracranial pressure * Myocardial infarction.
44
What is hypoxemia?
Low oxygen levels in the blood.
45
What is hypercapnia?
High levels of carbon dioxide.
46
What is the normal respiratory rate for adults?
12 to 20 breaths per minute.
47
Define tachypnea.
An increase in respiratory rate of more than 24 BPM in the adult.
48
What does dyspnea refer to?
Shortness of breath; difficult, labored breathing.
49
What is orthopnea?
Difficulty breathing when lying flat, relieved by sitting or standing.
50
What is the definition of apnea?
The absence of breathing.
51
What is the normal range for oxygen saturation?
95% to 100%.
52
What is the significance of arterial blood gases (ABG)?
They assess the respiratory component of acid-base balance and the adequacy of oxygenation.
53
What is hypotension?
Systolic blood pressure of less than 90 mm Hg or diastolic blood pressure of 60 mm Hg or less.
54
What can cause hypertension?
Risk factors include: * Family history * Sedentary lifestyle * Obesity * Ongoing stress * Smoking * Alcohol use * High salt and fat diet.
55
What is the definition of primary hypertension?
Hypertension with no known cause.
56
What is the definition of secondary hypertension?
Hypertension caused by a known illness process.
57
What is the most common site for indirect blood pressure measurement?
The upper arm at the brachial artery.
58
What should be avoided when taking blood pressure on the brachial artery?
If an arteriovenous fistula or shunt is present, or if the arm is diseased, has a cast, or is infusing IV fluids.
59
What is the significance of documenting pulse intensity?
It helps assess the strength of the pulse with each beat.
60
What is a bounding pulse?
A forceful volume that is obliterated only with difficulty.
61
What can cause a weak or thready pulse?
Causes include vasoconstriction, stiff vessel walls from disease, and shock.
62
After puberty, how does the blood pressure of females compare to that of males of the same age?
Females usually have lower blood pressure than males of the same age.
63
What factors may affect renal sodium handling and/or vascular resistance in females?
Females may affect renal sodium handling and/or vascular resistance.
64
How does blood pressure change for females after menopause?
Females generally have higher blood pressure than they did earlier in their lives.
65
Which ethnic group tends to have higher blood pressure compared to whites, Asians, or Hispanics of the same age?
African Americans tend to have higher blood pressure.
66
What is the relationship between obesity and hypertension in children and adults?
Obesity in children and adults is linked to a higher incidence of hypertension.
67
What arteries can be palpated to assess blood pressure?
* Radial artery at the wrist * Posterior tibial * Dorsalis pedis artery of the lower leg.
68
What is recorded when the palpated blood pressure value is felt at 70 mm Hg?
'70 palpable,' indicating palpated systolic pressure.
69
If the brachial artery is not accessible, which artery can be used for blood pressure measurement?
The popliteal artery behind the knee.
70
What conditions may require obtaining blood pressure on a lower extremity?
Injuries such as trauma or burns, or the presence of a cast, intravenous line, or arteriovenous shunt.
71
Where is the popliteal artery located?
Behind the knee in the popliteal space.
72
What is orthostatic hypotension?
An abrupt decline in blood pressure when a person moves from a supine to a sitting or standing position.
73
What blood pressure decline indicates orthostatic hypotension?
A decline of 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure.
74
What symptoms may accompany orthostatic hypotension?
* Dizziness * Fainting * Changes in mental status * Anxiety * Nausea * Rapid onset of pallor * Fast, shallow breathing.
75
Who can assess orthostatic hypotension?
Assessment cannot be delegated to unlicensed assistive personnel (UAP), but UAP may assist in obtaining measurements.
76
What is the recommended position for the patient before measuring orthostatic hypotension?
Have the patient remain in the supine position for 5 to 10 minutes.
77
What three positions should be measured for blood pressure and heart rate in orthostatic hypotension assessment?
* Supine * Sitting * Standing.
78
What is required for an official diagnosis of orthostatic hypotension?
A 20 mm Hg drop in systolic blood pressure or a 10 mm Hg drop in diastolic blood pressure.
79
What is an arterial line?
An indwelling catheter inserted into an artery to monitor blood pressure.
80
What is the purpose of an arterial line?
To monitor blood pressure in patients who are dangerously hypotensive or hypertensive.
81
What sounds are referred to as Korotkoff sounds?
The sounds heard when assessing blood pressure.
82
What is the auscultatory gap?
The absence of Korotkoff sounds noted in some patients after the initial systolic pressure.
83
What is Korotkoff I?
The first sound recorded as systolic pressure.
84
What is Korotkoff V?
The last sound heard before silence, indicating diastolic measurement.
85
What are some factors that contribute to blood pressure assessment errors?
* Defective equipment * Equipment not calibrated * Improper use of equipment * Patient not positioned correctly.
86
What can cause a falsely low blood pressure reading?
* Hearing deficit in assessing person * Arm positioned above heart level * Use of a cuff that is too wide.
87
What can cause a falsely high blood pressure reading?
* Assessing too soon after smoking or exercise * Use of a cuff that is too narrow.

Nsg 3100 (5 decks)

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